Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited. 607 ASAIO Journal 2016 Pulmonary Mechanical ventilation support for acute respiratory distress syndrome (ARDS) patients involves the use of low tidal vol- umes and positive end-expiratory pressure. Nevertheless, the optimal ventilator strategy for ARDS patients undergo- ing extracorporeal membrane oxygenation (ECMO) therapy remains unknown. A retrospective analysis of a consecutive series of adult ARDS patients treated with V-V ECMO from October 2012 to May 2015 was performed. Mechanical ven- tilation data, as well as demographic and clinical data, were collected. We assessed the association between ventilator data and outcomes of interest. The primary outcome was hospital survival. Secondary outcome was 30 day survival posthospital discharge. Sixty-four ARDS patients were treated with ECMO. Univariate analysis showed that plateau pressure was independently associated with hospital survival. Tidal volume, positive end-expiratory pressure (PEEP), and plateau were independently associated with 30 day survival. Multi- variate analysis, after controlling for covariates, revealed that a 1 unit increase in plateau pressure was associated with a 21% decrease in the odds of hospital survival (95% confi- dence interval [CI] = 6.39–33.42%, p = 0.007). In regards to 30 day survival postdischarge, a 1 unit increase in plateau pressure was associated with a 14.4% decrease in the odds of achieving the aforementioned outcome (95% CI = 1.75– 25.4%, p = 0.027). Also, a 1 unit increase in PEEP was asso- ciated with a 36.2% decrease in the odds of 30 day survival (95% CI = 10.8–54.4%, p = 0.009). Among ARDS patients undergoing ECMO therapy, only plateau pressure is associ- ated with hospital survival. Plateau pressure and PEEP are both associated with 30 day survival posthospital discharge. ASAIO Journal 2016; 62:607–612. Key Words: mechanical ventilation, ECMO, ARDS The first description of extracorporeal membrane oxygen- ation (ECMO) treatment in an adult patient with respiratory failure was in 1972. 1 Despite initial subsequent negative trials, 2 the conventional ventilator support versus extracorpo- real membrane oxygenation for severe adult respiratory failure (CESAR) study suggested possible benefits with extracorporeal lung support in patients with severe acute respiratory distress syndrome (ARDS). 3 Specifically, patients randomized to be transported to centers with capability to provide veno-venous ECMO had a higher 6 months survival (63% vs. 47%; p =0.03) compared with patients treated in their original centers. Later on, an observational study performed during the 2009 Influ- enza A (H1N1) pandemic showed lower mortality rates with ECMO utilization, compared with matched controls subjects. 4 Consequently, the Extracorporeal Life Support Organization (ELSO) published consensus guidelines for ECMO use in the adult patient with respiratory failure. 5 These guidelines recom- mended the initiation of ECMO therapy for patient with an arterial oxygen partial pressure (PaO 2 )/FIO 2 ratio below 100, while receiving an inspiratory fraction of oxygen (FIO 2 ) higher of 90%. Importantly, ELSO guidelines clarify that conven- tional treatments should initially be applied for 6 hours, before deciding whether ECMO therapy is required. Mechanical ventilation strategies for ARDS patients have been standard- ized since the publication of the multicenter NHLBI ARDSnet trial. 6 This study demonstrated that the application of low-tidal volume (TV) ventilation (6 ml/kg), while keeping plateau pres- sures lower than 30 cm H 2 O, resulted in an absolute reduction in hospital mortality of 9%. The utilization of positive end- expiratory pressure (PEEP) during mechanical ventilation has Mechanical Ventilation in Patients with the Acute Respiratory Distress Syndrome and Treated with Extracorporeal Membrane Oxygenation: Impact on Hospital and 30 Day Postdischarge Survival ARIEL M. MODRYKAMIEN,*† OMAR O. HERNANDEZ,‡ YUNHEE IM,* RYAN W. WALTERS,§ CALEB L. SCHRADER,† LAUREN E. SMITH,‡ AND BRIAN LIMA¶ Copyright © 2016 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0000000000000406 From the *Division of Pulmonary and Critical Care Medicine, †Respiratory Care Department, ‡Department of Cardiovascular ICU, Baylor University Medical Center, Dallas, Texas; §Division of Clini- cal Research and Evaluative Science, Creighton University, Omaha, Nebraska; and ¶Department of Cardiac Surgery, Baylor University Medical Center, Dallas, Texas. Submitted for consideration December 2015; accepted for publica- tion in revised form May 2016. Ariel Modrykamien designed the study, analyzed data, and wrote the manuscript. Omar O. Hernandez had full access to all data, which he col- lected, and takes responsibility for its integrity. Yunhee Im had full access to all data, which she collected, and takes responsibility for its integrity. Brian Lima had full access to all data, which he collected, and takes responsi- bility for its integrity. Ryan W. Walters provided analysis of data and per- formed statistical analysis. Caleb L. Schrader had full access to all data, which he collected, and takes responsibility for its integrity. Sara K. Kearns had full access to all data, which she collected, and takes responsibility for its integrity. Mark R. Medenceles had full access to all data, which she collected, and takes responsibility for its integrity. Lauren E. Smith had full access to all data, which she collected, and takes responsibility for its integ- rity. Rachel Dahl had full access to all data, which she collected, and takes responsibility for its integrity. Ruth Persons had full access to all data, which she collected, and takes responsibility for its integrity. Disclosures: The authors have no conflict of interest to disclose. Correspondence: Ariel M. Modrykamien, Medical Director, Depart- ment of Internal Medicine, Respiratory Care Services, Pulmonary and Critical Care Division, Baylor University Medical Center, 3600 Gaston Ave. Wadley Tower, Suite 960, Dallas, TX 75246. Email: ariel. modrykamien@baylorhealth.edu.